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Clinical Quality Team Lead

HealthCare Partners Garden City Full-Time
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HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 240+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities.
We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care.
Interested in joining our successful Garden City Team?  We are currently seeking a Clinical Quality Team Lead! 


JOB SUMMARY:
The Clinical Quality Team Lead (CQTL) is responsible for managing the day to day work of the clinical staff. The CQTL interfaces effectively with the Quality Field team as a facilitator, resource, educator, problem-solver and collaborator for HEDIS and quality related projects. The CQTL is responsible for staff and provider performance management which is tracked by designated metrics including CMS 4 and 5 Star ratings and NYSDOH 75th and 90th percentile gap closure utilizing health plan and internal systems gaps in care reports.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES:
  1. Applies clinical knowledge to effectively and efficiently coordinate quality initiatives and improve performance metrics.
  2. Manages the day to day HEDIS medical record review and coding processes which includes ongoing review of records retrieved and coded by field staff and records coded by nurses; over reads medical record charts to monitor accuracy, provides timely feedback to Quality Field team to address with providers and trains internal staff as appropriate.
  3. Identifies root causes related to providers’ low quality scores and develops appropriate comprehensive action/work plans; reviews documentation, coding practices and claims submission processes of providers, ensuring accuracy to capture appropriate gap closures for optimal outcomes; communicates findings to Quality Field team to address timely with providers.
  4. Manages and evaluates performance of staff related to clinical performance improvement activities; provides applicable coaching and training.
  5. Provides guidance to clinical staff on the utilization of targeting reports and reporting of all activities; monitors staff performance data to develop interventions to improve HEDIS, Stars, QARR Quality Incentive Program performance and effectiveness.
  6. Provides departmental training to new staff and ongoing staff development; develops training materials and job aids as applicable; maintains HEDIS manual.
  7. Maintains a knowledge base of HEDIS requirements and implementing clinical performance methods to improve HEDIS/Stars/QARR.
  8. Collaborates with Pharmacy, Behavioral Health (BH) and Medical Management departments on pharmacy, BH, CM and UM related measures to develop and drive clinical initiatives to improve HEDIS/Star/QARR performance.
  9. Supports data exchange processes with providers and ensures data is incorporated into HEDIS/QARR/Star rates timely as well as identifies additional data sources required as business needs/changes indicate.
  10. Works collaboratively with the Quality Field team to ensure medical records and reports retrieved from provider offices are loaded timely into the internal system, and compares the documentation in the medical record to specifications to determine if preventive and diagnostic services have been correctly and timely performed.
  11. Recommends methods to improve provider compliance to QI Program policies and procedures, including profiles/scorecards and efforts to increase provider compliance to clinical practice guidelines through medical record review.
  12. Assists with preparing, compiling, reviewing and submitting weekly, monthly and quarterly reports for management.
  13. Perform other duties or responsibilities as necessary or assigned.
QUALIFICATION REQUIREMENTS:
Skills, Knowledge, Abilities: 
  • Strong attention to detail with highly effective written and verbal communication and presentation skills
  • Strong critical thinking skills necessary to evaluate and respond to provider challenges and related team dynamics
  • Superior organizational, project management, group facilitation and relationship management skills
  • Comprehensive knowledge of HEDIS/QARR requirements for both Medicaid and Medicare lines of business, including medical record review and reporting processes
  • Demonstrated management skills with the ability to listen, motivate, direct others and build accountability to effectively complete projects and necessary tasks
  • Outstanding interpersonal skills with the ability to work collaboratively and build positive relationships with team members across the organization as well as influence with and without formal authority to drive performance outcomes
  • Proven ability to use data to identify opportunities for improvement, drive decision making and execute process/performance improvement
  • Proficient with Excel, Word, PowerPoint, Outlook
  • Ability to travel within the HCP service area should a provider require face to face clinical education, training, etc. on HEDIS

Training/Education:   
  • Clinical license (RN, LPN, MSW) in good standing required (NP, PA or PharmD preferred)                
Experience: 
  • 3 years HEDIS experience required
  • 3 years healthcare experience preferably in quality management
  • Experience with provider practice relationships and EMR / EHR experience preferred

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
 

Skills required

Coordinating
Leadership
Operations
Decision Making
Problem Solving
Management
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